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Progress Notes

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Turabo University

Calle Nuevo Leon


Albany, NY 29978 - 0000
Tel: 212 876-8768
Fax:

Hernandez, Johan
Sex: Female, Date of Birth: 01-18-1947, Account No: INT01232
Attending Provider: Marcus . Welby, M.D.
Encounter Date: 07-06-2015
Chief Complaint:
Other Complaints:
Past Medical History
Fever 780.60 Existing. Renal And Perinephric Abscess 590.2 Existing. Severe eczema 692.9 Existing. Swelling of both eyes
379.92 Existing.
Family History
Asthma: Mother. Cancer: Father. Heart Disease: Father, Mother.
Social History
Use Of Drugs/Alcohol/Tobacco: Drinks alcohol occasionally. Reports drinking beer, 1 drink per week. She denies her
alcohol consumption as being problem to self or family or others. She says she never indulges in 'binge' drinking. Denies
driving after drinking. She uses smokeless tobacco. She consumes one pack for day. Number of chews per day: 0. No. Of
pipes smoked per day: 0. Cigars smoked per day: 0. Does not drink caffeinated beverages. She has never used any illicit
drugs. She denies using street drugs with a needle. Has used/ is using cocaine. She has a sedentary lifestyle. Does not take
any exercise. She reports doing mild exercise like climb stairs or walk 2-3 blocks. She reports doing occasional vigorous
exercise ( work or recreation). She does not do any regular vigorous exercise for work or recreation.
Current Medication
clindamycin 150 mg capsule 3 Capsule Three Times A Day for 10 Days , Dispense 30 Capsule
hydralazine 50 mg tablet 1 Tablet Every Morning PRN for 30 Days , Dispense 30 Tablet
triamcinolone acetonide 0.147 mg/gram topical aerosol 2 times a day for 30 Days , Dispense 30 Unspecified
Benadryl 25 mg capsule every 4 to 6 hours for 30 Days , Dispense 900 Unspecified
vitamin A lotion 1 Every Morning to affect areas for 30 Days , Dispense 30 Unspecified
Vitamin D3 4,000 unit capsule to be applied to affect areas for 30 Days , Dispense 30 Unspecified
Allergy
PENICILLINS Moderate .
Health Maintenance
Type
Test
LB
ANA Panel

Status
Due

Due Date Last Done Last Result


06-24-2015

LB
LB

Complete Metabolic Panel


Lipid Panel

Due
Due

06-24-2015
06-24-2015

LB
LB
LB

CBC w/auto diff


Obstetric Panel
Renal Function Panel

Due
Due
Due

06-24-2015
06-24-2015
06-24-2015

LB
LB

Thyroid Antibody Panel


Pap smear

Due
Due

06-24-2015
06-24-2015

LB
LB
LB

Hemoglobin A1c
Due
Microalbumin
Due
Urinalysis, Complete W/Microscopic Due

06-24-2015
06-24-2015
06-24-2015

LB

STOOL GUAIAC

06-24-2015

Due

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Progress Notes

RL

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Mammo diagnostic

Due

06-24-2015

Physical Examination

Lab Order
Order No: LAB039 Dated: 07
HL7ADHOC : CBC

- 06

- 2015

Lab: Any Lab

Radiology Order
Order No: RAD00174 Dated: 07
CAT Scan: Chest

- 06

- 2015

Rad: Any Lab

Consults Ordered

Labs Reviewed
Radiology Reviewed

List of education material given


Follow up:

Marcus Welby, M.D.

This has been electronically signed on 07-06-2015

https://ut.prognocis.com/prognocis/scrPrint.jsp?id=4309&mode=default&tmpid=2&output... 7/22/2015